MEASURES AND QUALITY IMPROVEMENT

Transcription

1 MEASURES AND QUALITY IMPROVEMENT CO-LOCATION OF PRIMARY CARE AND BEHAVIORAL HEALTH Date: August 15, 2017

2 Introduction Today s Presenter Jacqueline Delmont, MD, MBA Delmont Healthcare Grassi & Co. General partner questions and comments will be addressed today via the chat function. 2

3 Agenda 1. Introduction 2. Measurement informed care 3. Process metrics 4. Outcomes metrics 5. Quality improvement strategies

4 Introduction This webinar will cover clinical and operational measures recommended for co-location of primary care and behavioral health services and an overview of strategies for quality improvement Depending on your setting and implementation design, some but not all of the measures may be appropriate for your clinic

5 What is co-location? Co-location of behavioral health in primary care settings Co-location of mental health and/or substance use services Target population: Patients with more complex and stable behavioral health problems (e.g. schizophrenia, bipolar disorder, severe depression, psychoses) that can be appropriately managed in a primary care setting Behavioral health services can be provided by a co-located psychiatrist or psychiatric nurse practitioner, preferably supported by psychologist or social worker 5

6 What is co-location? Co-location of primary care in behavioral health settings Target population: behavioral health patients with difficulty navigating routine primary care services Primary care services can be provided by any independently licensed provider (MD, DO, NP) Primary care services will include functions including: standard preventive care services screening and medical management issues specific to behavioral health population population health management for common chronic conditions collaboration with care management services 6

7 Why is Measurement Important? When you can measure what you are speaking about and express it in numbers, you know something about it; but when you cannot measure, when you cannot express it in numbers, your knowledge is of a meager and unsatisfactory kind; it may be the beginning of knowledge, but you have scarcely, in your thoughts, advanced to the stage of science. Lord William Kelvin ( )

8 Agenda 1. Introduction 2. Measurement informed care

9 Measurement Informed Care Standardizes response to treatment or any intervention Identifies and targets the symptoms not improving Monitors treatment progress Guides stepped care 5 Improves care quality and clinical outcomes 6 Assists with patient self-management 7 Aligns with health care and payment reform initiatives 9

10 Measurement-based treatment to target for populations Systematic screening of a target population to proactively identify patients in need of care and improvement rates Use of a registry to track a defined population of patients with identified behavioral health needs PHYSICAL HEALTH: BMI, Hb A 1C, BPC/Hypertension, LDL-C BEHAVIORAL HEALTH: PHQ-9, GAD-7 SUBSTANCE ABUSE: AUDIT / DAST-10 Adapted from: Behavioral Health Integration Framework Evaluation (BHI-FE) Project Implementation Guide Supplement. Organized, evidence-based care: BH Integration 10

11 Establish Measurement Monitoring Determine process and outcomes measures to be used to monitor progress and impact of implementation based on your program design and goals Some metrics may be tied to incentive payment opportunities Evaluate potential data sources that can be used to regularly report on measures: Clinical data from the EHR Scheduling data Claims data from payers Aggregated data sources (e.g. PSYCKES, ACOs, IPAs)

12 Agenda 1. Introduction 2. Measurement informed care 3. Process metrics

13 Process metrics aim to measure the following: Effectiveness did we achieve the expected results? (e.g. screening rates, referral rates, engagement with services and treatment) Capacity estimated volume based on FTEs Productivity visits per session/week/month/year Efficiency have we performed within our budget?

14 Examples of process metrics in behavioral health INTERVENTION TOOL / TREATMENT TIME LINE (follow-up) Screening for Clinical Depression PHQ-9 1 month, 3 months, 6 months. Until is discharged Antidepressant Medication Management Guide for depression treatment Remained on medication during the entire 12-week acute treatment phase. Adherence to Antidepressant Medications Management Effective Continuation Phase Treatment Remained on medication for at least 6 months. Adherence to Antipsychotic Medications for people with Schizophrenia Pre-Screening / Screening for Alcohol and other Drug Abuse-dependence Alcohol and Other Drug Dependence Treatment (AOD) Engagement of Alcohol and Other Drug Dependence Treatment (AOD) Cardiovascular monitoring for people with Cardiovascular disease and Schizophrenia At least 2 antipsychotic medications AUDIT-C / DAST-Q1 AUDIT/Full- DAST New episode of AOD dependence who initiated treatment Initiated treatment and had 2 or more additional services with of AOD dependence LDL-C test During 1 year of measurement and remained on medication for at least 80% of their treatment period Number of patients screened 1 visit within 30 days of initiation visit Initiation and 2 visits within 44 days During the measurement year Diabetes monitoring for people with Diabetes and Schizophrenia LDL-C test & HbA1c test During the measurement year Diabetes Screening for patients with Schizophrenia or Bipolar Disorder in Antipsychotic Medication Follow up after Hospitalization for Mental Illness Diabetes screening During the measurement year Within 7 or 30 days after discharge from hospitalization APA/APM report on dissemination of integrated care

15 Examples of process metrics INTERVENTION TOOL / TREATMENT TIME LINE (follow-up) New/established patients Annual wellness visit 1 month, 3 months, 6 months. Year 1, Year 2 etc Obesity screening BMI Number of patients screened Hypertension screening BP measurement Number of patients screened Breast cancer screening Mammogram yearly age During the measurement year Colon Cancer screening FOBT, colonoscopy 50 years > During the measurement year Immunizations: Flu shot Vaccination Number of patients immunized during flu season Cardiovascular monitoring for diabetes or hypertension LDL-C test During the measurement year Follow up after Hospitalization Within 7 or 30 days after discharge from hospitalization APA/APM report on dissemination of integrated care

16 Agenda 1. Introduction 2. Measurement informed care 3. Process metrics 4. Outcomes metrics

17 Outcomes measures aim to measure the following: Stabilized chronic health conditions and improvement rates (e.g. A 1C levels, depression scores, blood pressure, etc.) Increase in quality of life self-reporting Improved self-management skills associated to comorbid health conditions Lowered utilization dollars Fewer emergency department/urgent care visits Staff and patient satisfaction/experience

18 Examples of outcomes metrics 1. Depression Improvement Rate 2. Cholesterol Management for Patients with Cardiovascular Conditions 3. Controlling High Blood Pressure 4. Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) 5. Comprehensive diabetes care: LDL-c control (<100 mg%) 6. Potentially Preventable Emergency Department Visits (for persons with BH diagnosis) Milbank Memorial Fund. Integrating Primary Care into Behavioral Health Settings. Martha Gerrity

19 Agenda 1. Introduction 2. Measurement informed care 3. Process metrics 4. Outcomes metrics 5. Quality improvement strategies

20 Quality Improvement Consists of systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups.

21 One Quality Improvement Methodology for Engaging in Change: The Model for Improvement A framework to help organize and execute improvement work Tests are small, simple, and reversible Significant opportunity for learning Follow-Up Tests Wide-Scale Tests of Change Implementation of Change Very Small Scale Test Source: The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd Edition). Langley GL, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP, Note: This is just one performance improvement methodology; Lean Breakthrough has been frequently used at NYC Health + Hospitals. 21

22 One Quality Improvement Methodology for Engaging in Change: The Model for Improvement What are we trying to accomplish? Team Aims How will we know that the change is an improvement? Measurement What changes can we make that will result in an improvement? Tests of Change/Interventions ACT STUDY PLAN DO Source: Note: This is just one performance improvement methodology; Lean Breakthrough has been frequently used at NYC Health + Hospitals. 22

23 Developing an AIM Statement: A Quick Review of General Guidelines State Aim clearly Describe what needs to be improved Include numerical goals Creates the need for change and directs measurement Set stretch goals, but don t be too ambitious Communicates that maintaining status quo is not an option Be prepared to refocus the Aim if you find it is unrealistic Keep within a manageable scope Focus on a smaller part of issue Be realistic Avoid Aim Drift Make sure you don t slip back on your goals; continue to repeat Aim 23

24 Example: Project Charter focused on Diabetes Screening in Patients with Schizophrenia or Bipolar Disorder What are we trying to accomplish? How will we know that the change is an improvement? What changes can we make that will result in an improvement? Increase the percentage of diabetes screening tests to 82%* over the next 6 months for adult patients diagnosed with schizophrenia or bipolar disorder that are dispensed antipsychotic medications. We will accomplish this by: Developing a protocol in one clinic setting to ensure these patients obtain a screening for diabetes at least annually. In-servicing clinicians to obtain necessary information about the protocol to ensure their understanding. % of diabetes screening tests given to adult patients with schizophrenia or bipolar disorder that are dispensed antipsychotic medications % of providers in-serviced about the screening protocol % of patients contacted to come to the specific clinic setting to complete the diabetes screening test ACT STUDY PLAN DO Creating outreach strategies to effectively communicate the need to patients that they must come to the clinic to complete the test. *eqarr Report 2016 State Medicaid Average for this measure is 82%: 24

25 Quality Improvement General Rules for Engagement Form an Interdisciplinary Team Set Aims/What Your Team Hopes to Accomplish Establish Measures* to Determine Improvement Select Tests to Make Changes Keep it Simple Conduct Small Tests of Change Implement Changes on a Larger Scale, with Tweaks, Based on What s Been Learned from the Tests *A note about data collection for measurement in quality improvement How much data is really enough? Measurement for improvement is different from measurement used in research (see next slide) Sources: Institute for Healthcare Improvement (IHI): World Health Organization (WHO): 25

26 A Note About Measurement for Research vs. Measurement for Quality Improvement Measurement for Research Measurement for Quality Improvement Purpose To discover new knowledge To bring new knowledge into daily practice Tests One large blind test Many sequential, observable tests Biases Control for as many biases as possible Stabilize the biases from test to test Data Duration Gather as much data as possible, just in case Can take long periods of time to obtain results Gather just enough data to learn and complete another cycle Small tests of significant changes accelerates the rate of improvement Source: World Health Organization (WHO): 26

27 Experimenting/Testing versus Implementing Follow-Up Tests Wide-Scale Tests of Change Implementation of Change Experimenting/Testing Changes are not permanent Significant opportunity for learning Does not require universal awareness Implementing Supporting processes are required in order to become routine Requires increased awareness Takes longer Requires additional support Must address social aspects Very Small Scale Test Source: The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2 nd Edition). Langley GL, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP,

28 Upcoming Webinars to Support Implementation Implementation Physical health screening approaches Behavioral health screening tools Billing guidance 28

29 Questions? 29

30 For more information ONECITY HEALTH SUPPORT DESK: PRESENTER: Call with the subject line PCBH Integration Question Jacqueline Delmont, MD, MBA Delmont Healthcare Grassi & Co. Hours of Operation: Monday through Friday 9am to 5pm ET 30

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